In Brazil, the vaccination of both children and adults is coordinated by the National Immunization Program (PNI). Data from the PNI\u2019s online information system (SI-PNI\/DataSUS), accessed by Pesquisa<\/em> FAPESP <\/em>on February 10, show that in 2021, even the most successful of these nine vaccines were only given to 71% of the target population. Just two of them\u2014the triple viral vaccine against measles, mumps, and rubella (MMR) and the pneumococcal vaccine, which helps prevent pneumonia, meningitis, and otitis\u2014achieved this rate, which is already below the level recommended by the PNI. The rest had even lower levels of coverage, including the BCG, which protects against tuberculosis and is given in maternity wards (see graph above<\/em>).<\/p>\n \u201cThese numbers indicate that at least 900,000 children in Brazil were not vaccinated in 2021. We\u2019re getting close to the rates we had in the 1980s,\u201d says Carla Domingues, a sociologist who directed the PNI from June 2011 to July 2019.<\/p>\n Office for Social Communication, Health Department, Brazilian Ministry of Health | Brazilian Ministry of Health <\/span><\/a> In 1986, Darlan Rosa, a graphic artist from Minas Gerais, created the character Z\u00e9 Gotinha to reduce children\u2019s fear of vaccination during the polio eradication campaign, and it was later adopted as the PNI\u2019s mascotOffice for Social Communication, Health Department, Brazilian Ministry of Health | Brazilian Ministry of Health <\/span><\/p><\/div>\n Created in 1973, the program was one of the first health policies aimed at universal immunization in the country. For a long time, it was seen as an example of success worldwide. In 1977, the PNI began routine administration of the BCG vaccine, in addition to vaccines for measles, polio, and DTP, which protects against diphtheria, tetanus, and whooping cough (pertussis). Routine vaccination, together with mass immunization campaigns and barrier vaccinations to contain outbreaks, eliminated rubella and the polio virus in the country, the latter of which caused some 10,000 cases of the disease a year in the 1980s. Measles, diphtheria, and whooping cough were all close to being stamped out. The program was gradually expanded, now offering 29 vaccines free of charge to children and adults. After reaching almost universal coverage between 2010 and 2015, something changed and childhood vaccination rates began to fall. There was a slight recovery in 2018, but the downward trend was resumed the following year and worsened alongside the pandemic.<\/p>\n \u201cWhen the decline became evident in 2017, the Ministry of Health acted in partnership with state and municipal health departments and scientific societies to promote a national response. The numbers rose again, but then they plummeted,\u201d recalls Domingues, who was in charge of the PNI at the time. \u201cMaintaining high vaccination rates among the population is a job that requires continuity,\u201d she explains. Public health experts say that this continuity can only be achieved in a well-structured health system.<\/p>\n Current rates for at least nine vaccines given to children\u2014BCG, hepatitis A, hepatitis B, meningococcal C, pentavalent, pneumococcal, polio, rotavirus, and MMR\u2014were 23 to 39 percentage points lower in 2021 than in 2015 (see graph above<\/em>). \u201cAlthough the data is not 100% accurate, this situation could lead to the resurgence of diseases that have previously been eliminated or controlled,\u201d says Renato Kfouri, president of the Immunization Department at the Brazilian Society of Pediatrics (SBP) and director of the Brazilian Society of Immunization (SBIM) and a private vaccination clinic. \u201cOne of the diseases that usually appears first is measles, which is caused by an easily transmitted virus that is still uncontrolled in many countries. There is also a risk that cases of diphtheria and pertussis will increase and that polio will reappear.\u201d<\/p>\n Although municipal authorities have until March to submit their data to the PNI, the 2021 numbers are highly unlikely to reach the recommended levels. The World Health Organization (WHO) recommends that the BCG and rotavirus vaccines, the latter of which reduces the risk of severe diarrhea, be given to at least 90% of children. The recommended coverage for the others is 95%. This is the only way to achieve herd immunity and protect both vaccinated children and those not immunized against these diseases.<\/p>\n Fernando Fraz\u00e3o \/ Ag\u00eancia Brasil <\/span><\/a> Child being vaccinated against polio during an immunization campaign in Rio de Janeiro in 2018Fernando Fraz\u00e3o \/ Ag\u00eancia Brasil <\/span><\/p><\/div>\n Pesquisa<\/em> FAPESP<\/em> asked the Ministry of Health for its opinion on the causes of the decline and the severity of the situation, as well as an overview of what actions have been taken to reverse the trend. The ministry replied that \u201cit has been assessing falling vaccine coverage through studies of vaccine coverage surveys and rapid monitoring.\u201d It also says that other initiatives have been adopted, such as the strengthening of joint actions with the primary health care services, which are responsible for vaccinations and implementing national immunization campaigns, such as the \u201cmultivaccination campaign\u201d that took place in October and November of 2021. The ministry stated that it is working on increasing the number of professionals qualified to work in vaccination and that it has signed a partnership with the Oswaldo Cruz Foundation (FIOCRUZ) to implement project Reconquista das Altas Coberturas Vacinais<\/em> (\u201cRestore high vaccine coverage\u201d), the pilot for which will shortly begin testing tailored actions designed to raise the vaccination rate of children in 41 municipalities in the Brazilian states of Amap\u00e1 and Para\u00edba.<\/p>\n The drop in vaccination coverage over the last two years can be partly attributed to the novel coronavirus pandemic. Recent studies comparing the numbers of children being vaccinated in the years before COVID-19 with the numbers recorded after the pandemic began suggest the impact is not negligible.<\/p>\n In an article published in the Journal of Medical Microbiology <\/em>in August 2021, Marcelle Moura Silveira, a biochemist from Anhanguera College in Pelotas, Rio Grande do Sul, and her colleagues from the Federal University of Pelotas (UFPel) analyzed the change in uptake of four vaccines (BCG, meningococcal, pneumococcal, and DTP). The biggest drop occurred in 2020, when the pandemic first began. Between 2019 and 2020, application of the four vaccines dropped by between 10 and 23 percent.<\/p>\n L\u00e9o Ramos Chaves <\/span><\/a> Child being vaccinated against measles during an immunization campaign in Rio de Janeiro in 2018L\u00e9o Ramos Chaves <\/span><\/p><\/div>\n And these were not the only ones for which uptake fell in the period. At the Federal University of Minas Gerais (UFMG), a group led by T\u00e9rcia Moreira Ribeiro da Silva compared the coverage of another important childhood vaccine\u2014the MMR\u2014during two periods: from April 2019 to March 2020, before social-distancing measures were introduced in Brazil, and from April to September 2020, when people started staying at home and city streets were quieter. According to the results, published in the journal BMC Infectious Diseases <\/em>in December 2021, the number of vaccine doses administered monthly fell by an average of 43%, from 1.6 million in the first period to 935,000 in the second.<\/p>\n The drop was uneven across the country and most profound\u2014and statistically significant, ranging from 48% to 65%\u2014in seven states: three in the North (Acre, Amazonas, and Roraima), two in the Northeast (Para\u00edba and Sergipe), one in the Southeast (Rio de Janeiro), and one in the South (Santa Catarina). After analyzing the distribution of municipalities with low coverage, the researchers found that in the North and parts of the Northeast, they are often located very close together, forming pockets of people vulnerable to infection by measles, mumps, and rubella. \u201cThere is a greater likelihood that these viruses, especially measles, will circulate again in these areas,\u201d says T\u00e9rcia Ribeiro da Silva.<\/p>\n The pandemic is one of the factors behind the decline, but it is unlikely to be the only contributor. In a study published in Revista Mineira de Enfermagem <\/em>in 2020, the UFMG team observed that the MMR vaccine was slightly less available in the municipalities in the North than in the other four regions. Ed Wilson Vieira, T\u00e9rcia Ribeiro da Silva, and their colleagues examined the situation at 19,752 vaccination centers across Brazil based on records taken by the Primary Healthcare Quality Improvement Program in 2013 and 2014 (a program terminated by the current administration) and found that the probability of a vaccine being available was lower at the locations with the worst infrastructure. This includes centers that had no vaccination room or shared one with other activities, and some that did not even have an exclusive refrigerator or cooler to store the vaccines.<\/p>\n Fernando Fraz\u00e3o \/ Ag\u00eancia Brasil <\/span><\/a> Child being vaccinated against COVID-19 in S\u00e3o PauloFernando Fraz\u00e3o \/ Ag\u00eancia Brasil <\/span><\/p><\/div>\n Perhaps it is no coincidence that the reemergence of the measles virus in Brazil in 2018 started in the North. After recording just a few cases in 2015, Brazil was certified free of the infectious agent the following year by the Pan American Health Organization (PAHO). With the drop in vaccination rates, however, the measles virus begun circulating once again. There were 10,400 cases recorded in 2018; 21,000 in 2019; and 8,400 in 2020, resulting in tens of deaths.<\/p>\n As one of the countries most affected by the COVID-19 pandemic, with 27.5 million people infected with the novel coronavirus and almost 640,000 deaths recorded by mid-February of this year, Brazil was not the only nation to show a significant reduction in immunization against other diseases. A group led by pediatrician Anita Shet from Johns Hopkins University, USA, gathered information on the number of doses of the DTP and measles vaccines administered in 170 countries in 2019 and 2020. Published in The Lancet GlobalHealth <\/em>in February, the study identified a drop of approximately 30% in global vaccination rates, primarily in the first half of 2020. It included data from 27 countries and three territories in the Americas. In 16 of them (53%), there was at least a partial interruption in vaccination due to reduced demand, difficulties obtaining vaccines, staff shortages, and other factors. According to estimates by the WHO and the United Nations International Children’s Emergency Fund (UNICEF), an additional 4 million children were not vaccinated in 2020, bringing the total number of nonimmunized children in the year to 23 million.<\/p>\n Refined over more than two centuries, vaccines have become one of humankind\u2019s most effective life-saving strategies. Data from the WHO, for example, show that the use of vaccines reduced the worldwide number of measles cases from 854,000 in 2000 to around 150,000 in 2020 and the number of mumps cases from 544,000 to 270,000 in the same period. They also suggest that vaccines prevent the death of 4 to 5 million children each year. According to the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, USA, the widespread use of vaccines in recent decades has reduced the number of deaths of children aged under 5 from diseases totally or partially preventable by vaccination from 5.5 million in 1990 to 1.8 million in 2017.<\/p>\n The global increase in vaccination coverage over the last four decades is undeniable. In a recent study led by Stephen Lim and Jonathan Mosser of the IHME, an international group of researchers looked at the routine use of 11 vaccines in 204 countries between 1980 and 2019. Published in The Lancet<\/em> in August last year, the study revealed the existence of a universal pattern. The proportion of people immunized\u2014particularly with the measles, polio and diphtheria, tetanus, and whooping cough vaccines\u2014has grown worldwide, from about 40% of the global population in the 1980s to around 80% at the end of the last decade. In that time span, the total number of unvaccinated children dropped from 56.8 million to 14.5 million. Vaccination coverage increased rapidly in the 1980s and slowed slightly in the 90s and 2000s: in 2010, almost 120 countries managed to administer the three vaccines to 90% of children. From that year onward, however, the decline set in: vaccination rates fell in 94 countries, including Brazil, one of the few in which there were children who did not receive any of the main vaccines in 2019.<\/p>\n In 2018, when the most consistent signs of a drop in childhood immunization emerged in the country, a report by Pesquisa FAPESP <\/em>interviewed pediatricians, immunologists, epidemiologists, and health authorities in search of an explanation. At the time, experts listed at least nine reasons for the phenomenon (see<\/em> Pesquisa FAPESP issue<\/em> n\u00ba 270<\/em><\/a>), ranging from a misconception that some of the diseases preventable by vaccines no longer exist to a lack of knowledge of the vaccine schedule, which has become more complex and requires multiple visits to the health center before children reach the age of 15 months (see the online version of the report<\/em>). Other potential reasons included a fear of potential adverse reactions, a fear that a high number of vaccines could overwhelm a child\u2019s body, and parents not having enough time to take their children to health centers, which are usually only open during business hours. A change to the country\u2019s system for recording vaccination data also had an impact. In 2012, all 36,000 vaccination posts nationwide switched to a new, more laborious system that requires staff to record the patient\u2019s name and other personal data. Other factors that cannot be ruled out include the effects of fake news on the topic and the organized efforts of antivaccination groups, which although incipient in Brazil, are more active in Europe and North America\u2014the recent protests by truck drivers against Canada’s COVID-19 vaccination passport, for example.<\/p>\n \u201cAll these reasons exist and remain valid. The impact of some seems to have been reinforced in recent years as the antivaccination movement has grown, fake news on social media has intensified, and Brazilian public figures have spoken openly against vaccines,\u201d says Fernando Barros, a pediatrician, epidemiologist, and professor at UFPel and the Catholic University of Pelotas (UCPel) who studies childhood vaccination rates. \u201cEveryone used to speak very carefully and responsibly about vaccines. Like any drug, they can cause adverse events, but these are extremely rare,\u201d says Eliseu Waldman, an epidemiologist from the School of Public Health (FSP) at the University of S\u00e3o Paulo (USP).<\/p>\n Dave Chan\u2009\/\u2009AFP via Getty Images<\/span><\/a> Protests against mandatory COVID-19 vaccination passports in Toronto, Canada, in early FebruaryDave Chan\u2009\/\u2009AFP via Getty Images<\/span><\/p><\/div>\n In addition to these factors, aggravated by the pandemic\u2019s impact on health services, there are others, such as infrastructure problems and the need to improve the training of vaccination center staff. When planning the Reconquista das Altas Coberturas Vacinais<\/em> project with the Ministry of Health in December, Akira Homma, a virologist and senior scientific advisor at FIOCRUZ\u2019s Institute for Technology in Immunobiologicals (Bio-Manguinhos), visited 15 municipalities in Para\u00edba and Amap\u00e1 and talked to mayors, secretaries, and the staff responsible for giving vaccines. He found that the conditions at vaccination posts were highly heterogeneous. Some were very clean and well equipped, while others had infrastructure problems, such as no adequate refrigerator to store vaccines. He observed that the staff administering vaccines, who earned low wages and sometimes had to supplement their income with second jobs, were almost always unmotivated. \u201cWe need to value the work of those on the front lines and encourage them to be more active in the search for people who are not fully vaccinated, in addition to making society see immunization as one of the most important ways of ensuring the good health of the population,\u201d says Homma.<\/p>\n Another problem is the lack of coordination in the Brazilian public health system (SUS) and within the PNI, marked by a worsening of indicators related to various diseases and infant mortality. Since mid-2019, the program\u2019s director has been replaced four times. Pesquisa<\/em> FAPESP<\/em> requested an interview with Samara Furtado Carneiro, who took over leadership of the PNI in January, but was turned down by the ministry’s press office. \u201cStates and municipalities work well, but national coordination is needed,\u201d says Barros, from UFPel.<\/p>\n The list of potential causes for the continuing fall in vaccination coverage in the country, written in 2018, offers various plausible explanations, but they vary from one region to another. To what extent each of them contributes to the phenomenon is still unknown. With a new national survey nearing completion, Carla Domingues and Jos\u00e9 Cassio de Moraes, an epidemiologist from the Santa Casa de S\u00e3o Paulo School of Medical Sciences, are intending to answer some of these questions and better understand why some Brazilians have stopped vaccinating their children in recent years. With funding from the Ministry of Health and the Brazilian National Council for Scientific and Technological Development (CNPq), a group of researchers is interviewing 40,000 parents and guardians of children in 27 state capitals and other cities with more than 200,000 inhabitants, and taking photographs of vaccination cards. \u201cWe want to know what proportion of children are fully vaccinated, which parents have most difficulty taking their children to health centers, how many are missing vaccines, and other information,\u201d says Moraes.<\/p>\n The former involves taking measurements to quantify a given attribute\u2014the number of unvaccinated children in a city, for example\u2014and then using statistical methods to search for relationships with other attributes. The approach is used to identify patterns and trends associated with a phenomenon. It can help give a rough idea of the size of the problem.<\/p>\n Qualitative studies, meanwhile, involve gathering information through interviews and observations, helping shed light on the reasons behind the patterns and trends. \u201cIn our research, we epidemiologists often find associations between two factors and present plausible hypotheses to explain them, but it is qualitative studies, which identify the reasons given by people themselves, that allow us to confirm or refute these explanations,\u201d says Fernando Barros, from UFPel.<\/p>\n The experts interviewed for this report raised many questions that are yet to be answered using one investigative strategy or another, such as: what proportion of children are fully immunized in Brazil? Is vaccine coverage homogeneous? Are there pockets of unvaccinated people? If so, where are they? Are vaccines available at health centers in regions with low immunization rates? What is the structure of these health centers like? What are the most efficient strategies for informing the population about the importance of immunization? Are vaccination posts difficult to access? Do parents know how many and which vaccines their children should have? Do they consider it important to vaccinate their children? Do they trust vaccine safety and efficacy? Are they antivaccine? For what reasons have they not had their children vaccinated? How effective is the dissemination of vaccination campaigns via traditional media and social media? In addition to many others.<\/p>\n \u201cWe need to know the response to many of these questions to be able to identify strategies for efficiently restoring confidence in vaccines and the importance of taking them,\u201d says Eliseu Waldman, from USP.<\/div>\n Scientific articles<\/strong>![\"\"](\"https:\/\/revistapesquisa.fapesp.br\/wp-content\/uploads\/2022\/04\/032-039_capa_vacinacao_313-5-1140.jpg\")
\n <\/picture>Alexandre Affonso<\/span>\n\n <\/picture>Alexandre Affonso<\/span>\n
\n<\/strong>
\nTo reverse the decline in childhood immunization, we first need to know the true scale of the problem and identify its real causes. Experts say that to do this, the issue needs to be investigated via two distinct and complementary strategies: quantitative and qualitative studies.<\/p>\n
\nSILVEIRA, M. M.\u00a0et al<\/em>.\u00a0Effect of COVID-19 on vaccination coverage in Brazil<\/a>.\u00a0Journal of Medical Microbiology<\/strong>. Nov. 30, 2021.
\nDA SILVA, T. M. R.\u00a0et al.<\/em>\u00a0Number of doses of Measles-Mumps-Rubella vaccine applied in Brazil before and during the COVID-19 pandemic<\/a>.\u00a0BMC Infectious Diseases<\/strong>. Dec. 9, 2021.
\nVEIRA, E. W.\u00a0et al.<\/em>\u00a0Estrutura e localiza\u00e7\u00e3o dos servi\u00e7os de vacina\u00e7\u00e3o influenciam a disponibilidade da tr\u00edplice viral no Brasil<\/a>.\u00a0Revista Mineira de Enfermagem<\/strong>. Feb. 2020.
\nSHET, A.\u00a0et al.<\/em>\u00a0Impact of the SARS-CoV-2 pandemic on routine immunisation services: evidence of disruption and recovery from 170 countries and territories<\/a>.\u00a0The Lancet Global Health<\/strong>. Feb. 10, 2022.
\nGBD 2020, RELEASE 1, VACCINE COVERAGE COLLABORATORS.\u00a0Measuring routine childhood vaccination coverage in 204 countries and territories, 1980\u20132019: a systematic analysis for the Global Burden of Disease Study 2020, Release 1<\/a>.\u00a0The Lancet<\/strong>. Aug. 7, 2021.<\/p>\n","protected":false},"excerpt":{"rendered":"The pandemic has exacerbated a decline in immunization rates, which fell by 65% in some states in 2020","protected":false},"author":16,"featured_media":434034,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[156,3674,159],"tags":[229,260,256],"coauthors":[105],"class_list":["post-434010","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-cover","category-covid-19-en","category-science","tag-epidemiology","tag-public-health","tag-public-policies","position_at_home-sumario","keywords-coronavirus-en","keywords-coronavirus-en-2","keywords-covid-19-en","keywords-sars-cov-2-en","keywords-sars-cov-2-en-2","keywords-vaccine","keywords-virology"],"acf":[],"_links":{"self":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/posts\/434010","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/users\/16"}],"replies":[{"embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/comments?post=434010"}],"version-history":[{"count":4,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/posts\/434010\/revisions"}],"predecessor-version":[{"id":434087,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/posts\/434010\/revisions\/434087"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/media\/434034"}],"wp:attachment":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/media?parent=434010"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/categories?post=434010"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/tags?post=434010"},{"taxonomy":"author","embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/coauthors?post=434010"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
![](\"\/wp-content\/uploads\/2022\/04\/032-039_capa_vacinacao_313-0-desktop-true.png\")
\n <\/picture>Alexandre Affonso<\/span><\/div>\n
Aspects of the problem still unknown